The Benefits within this scheme, to be provided on a cashless basis to the Beneficiaries
up to the limit of their annual coverage, package charges on specific procedures
and subject to other terms and conditions outlined herein, are the following:

a)

The scheme shall provide coverage for meeting expenses of hospitalization for medical
and/or surgical procedures including maternity benefit, to the enrolled families
and up to Rs.30,000 per family per year subject to limits, in any of the government
hospitals and private hospitals and nursing homes. The benefit to the family will
be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed of
individually or collectively by members of the family per year.

b)

Pre-existing conditions/diseases are to be covered from day one, subject to the
exclusions given in Annexure 8.

c)

Coverage of health services related to surgical nature shall also be provided on
a basis.

The Insurer shall provide coverage for the following treatments/procedures:

Pre and post hospitalization costs up to 1 day prior to hospitalization and up
to 5 days from the date of discharge from the hospital shall be part of the package
rates.

e)

Maternity and Newborn Child Coverage will be covered as per details provided
below:

1.

This means treatment taken in hospital/nursing home arising from childbirth including
normal delivery / caesarean section and/ or miscarriage or abortion induced by accident
or other medical emergency subject to exclusions given in Annexure 8.

2.

Newborn child shall be automatically covered from birth up to the expiry of the
policy for all the expenses incurred in taking treatment at the hospital as in-patient.
This benefit shall be a part of basic sum insured and new born will be considered
as a part of insured family member till the expiry of the policy subject to exclusions
given in Annexure 8.

3.

Above shall be covered from day one of the inception of the scheme and normal
hospitalisation period for both mother and child should not be less than 48 hours
post delivery.

4.

The maximum benefit allowable under this clause will be up to Rs.4,500/- subject
to limits under table of benefits. This benefit shall be a part of basic sum insured.
Government of Punjab can revise these rates based on the costs structure in their State,
however, the ratio of cost of caesarean and normal deliveries will be as prescribed
in Annexure 6.

The charges for medical/ surgical procedures/ interventions under the Benefit package
will be no more than the package charge agreed by the Parties, for that particular
year. The same can be amended by mutual consent for the next year. Provided that
the Beneficiary has sufficient insurance cover remaining at the time of seeking
treatment, such listed services will not be subject to pre-authorization by the
Insurer. The list of common procedures and package charges is set out in Annexure
– 6 to this tender document, and will also be incorporated as an integral part of
service agreements between the Insurer and its empanelled service providers. [States
and Insurer to review Annexure – 6 to check on suitability of list and package charges
by procedure].

Procedures which are not on the list set out in Annexure – 6 to this tender document
would still be included as Benefits under this scheme, but will be subject to a
pre-authorization procedure, as per Clause – 14(2). As part of their regular review
process within the Co-ordination Committee, the Parties shall review information
on common unlisted procedures and seek to introduce them into the listed package
with appropriate package charge.